A local hemostatic agent for the management of postpartum hemorrhage due to placenta previa and placenta accreta: a cross-sectional study

Impact of prior use of topical hemostatic agents on trial of labor after cesarean: Insights from a multicenter cohort study

OBJECTIVE

To evaluate the association between a topical hemostatic agent used at the time of cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean (TOLAC).

METHODS

A multicenter retrospective cohort study was conducted (2005-2021). Parturients with a singleton pregnancy in whom a topical hemostatic agent was placed during the primary cesarean delivery were compared with patients in whom no such agent was placed. We assessed the uterine scar disruption rate after the subsequent TOLAC and the rate of adverse maternal outcomes. Univariate analyses were followed by multivariate analysis (adjusted odds ratio [aOR]; 95% confidence interval [CI]).

RESULTS

During the study period, 7199 women underwent a trial of labor and were eligible for the study; 430 (6.0%) had prior use of a hemostatic agent, 6769 (94.0%) did not. In univariate analysis, a history of topical hemostatic agent use was not found to be significantly associated with uterine scar rupture, dehiscence, or failed trial of labor. This was also confirmed on multivariate analysis for uterine rupture (aOR 1.91, 95% CI 0.66-5.54; P = 0.23), dehiscence of uterine scar (aOR 1.62, 95% CI 0.56-4.68; P = 0.37), and TOLAC failure (aOR 1.08, 95% CI 0.79-1.48; P = 0.61).

CONCLUSION

A history of hemostatic agent use is not associated with an increased risk for uterine scar disruption after subsequent TOLAC. Further prospective studies in other settings are needed to strengthen these findings.

Advanced Ovarian Pregnancy: A Case Report of Misdiagnosis and Surgical Outcomes

Background

Ovarian pregnancy is rare and difficult to diagnose preoperatively, especially in advanced gestational age. Misdiagnosis can increase the chance of emergent complications.

Case

A misdiagnosed case of a 33-week ovarian pregnancy woman who underwent surgery due to a preoperative diagnosis of a dead fetus in utero, and transverse lie was reported with eventful surgical outcomes. This case resulted in the delivery of a dead fetus and a sudden massive hemorrhage that occurred after placental detachment. Oophorectomy could not be performed due to severe bowel adhesions and multiple feeding vessels from the bowel at the posterior part of the left ovary. The placental site was sutured at multiple sites, and local hemostatic agents were placed for hemostasis. Postoperatively, she received multiple transfusions and was safely discharged after 10 days.

Conclusion

Obstetricians must be acutely aware of this condition, especially while performing sonography preoperatively, for better outcomes.

Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents

Peripartum hemorrhage accounts for 8% of maternal deaths in the United States, and nearly 27% worldwide. A growing need exists for tactics to spare morbidity given a rise of abnormal placentation that contributes to excessive blood loss at the time of delivery. Approaches such as compression sutures, balloon tamponade, and pelvic artery embolization are not without side effects and potential implications for future fertility. The use of topical hemostatic agents has become widespread in gynecologic and obstetric surgery despite a paucity of distinct studies in the field, and may allow providers to increasingly avoid cesarean hysterectomy. A variety of topical hemostatic agents exist along a wide cost continuum, each characterized by specific efficacy, advantages, drawbacks, and often gaps in long-term data to support safety and impact on future fertility. Herein, we comprehensively review these agents and illustrate a nontraditional use of Monsel solution applied directly to the placental bed in a case of focal placenta accreta. This ultimately contributed to successful uterine preservation with no known adverse sequelae. Monsel solution may have a role in establishing hemostasis in the setting of abnormal placentation, and may be a particularly attractive alternative in resource-poor nations.